Provider Demographics
NPI:1538736467
Name:TEAGUE, JACQUELYN MICHELLE (OTR)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:MICHELLE
Last Name:TEAGUE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:MICHELLE
Other - Last Name:WOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:3651 SANDY BROOK DR UNIT 206
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78665-1554
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2535 LONE STAR DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75212-6313
Practice Address - Country:US
Practice Address - Phone:830-355-8331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11979225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist